Examining a renal patient

Dr Jack Marjot

Dr Louisa Churcher

Dr Stephanie Bailey

OSCE-Aid Presents:

1. Mode of current / previous renal

replacement

2. Adequacy of renal replacement

3. Complications of renal failure

4. Complications of immunosuppression

5. Clues as to cause of kidney failure

Key Things to Look for in Renal

Examination

Structure of the renal exam

1. WIPER

2. Around the bed

3. Hands, arms

4. Neck, face

5. Chest, abdomen

6. Legs

7. Completion of examination

Structure of the renal exam

1. WIPER

2. Around the bed1. Diabetes monitoring

2. Hearing aid (Alports)

3. Drugs

3. Hands1. Fingerprick

monitoring

2. Cap refill, temperature

3. Asterixis (uraemia)

4. Tremor (ciclosporin)

4. Arms1. AV fistula (inspection,

palpation, auscultation)

2. Bruising, excoriations

3. Raise arm

4. Offer BP

5. Neck1. JVP

2. Tunneled lines

3. Parathyroidectomy scar

6. Face1. Mucous membranes

2. Conjunctival pallor

3. Skin malignancies / cushingoid facies / gum hypertrophy

7. Chest1. Skin turgor

2. Auscultate – pericardial rub

3. Lung bases + sacral oedema

8. Abdomen1. Inspect

– Scars (nephrectomy/RM)

– Tenchkoff catheter / surrounding skin

– Inguinal masses

– Subcut injection sites

2. Palpate– Iliac fossa mass

– Ballot for enlarged native kidneys

3. Percuss– Dull mass in iliac fossa

– Shifting dullness

4. Bruit

9. Legs1. Oedema

Mode of current /

previous renal

replacement

Types of Renal Dialysis

Access

• Temporary neck lines in

the femoral/jugular –

“Vascath”

– Non tunneled

– Temporary approx. 7 days

• Intermediate “Permacath”

– Tunneled line

– Dual lumen usually into RIJ

– Lasts months

• AV fistula

– Takes 4-6 weeks to mature

Fistula

• Location:

– Radiocephalic fistula – scar at the wrist

– Brachiocephalic fistula – scar at elbow crease

• Inspection:

– Skin changes (infection, ischemia of hand [steal syndrome])

– Bandages suggesting recent needling

– Length (rule of 6s)

• Palpation:

– CRT / temp

– Palpable thrill

– Tenderness

– Raise arm

• Fistula should collapses

if no outflow obstruction

• Auscultation:

– Audible bruit

Peritoneal dialysis

• Tenchkoff

catheter

• Scars

Renal transplant

• Transplantation Scars:

– Rutherford Morrison

(reverse hockey stick

usually in RIF).

• Renal transplant:

– Inspection:

• R-M scar

• Smooth mass under scar

– Palpate:

• Able to get above and below

mass

• No movement on respiration

• Tender? Warm? – possible

rejection.

– Percuss:

• Dull to percussion

– Auscultate:

• Possible bruit audible

Adequacy of renal

replacement

HYDRATION STATUS

HYDRATION STATUS

HANDS

– Warm? Capillary refill time? Radial pulse

ARMS

– BP (offer lying-standing)

NECK

– JVP

FACE

– Mucous membranes

– Tongue

HYDRATION STATUS

CHEST

– Skin turgor

– Central refill time

– Palpate the apex beat

– Auscultate heart (heart failure – 3rd

heart

sound)

– Lung bases (pulmonary oedema – bibasal fine

crepitations)

– Sacral oedema

LEGS

– Peripheral oedema

URAEMIA

Features of uraemia

• Asterixis

• Bruising (platelet dysfunction)

• Pruritus / excoriations

• Lemon tinged skin

• Pericarditis:

– Chest pain

– Pericardial rub

– Signs of tamponade; pulses paradoxus, Becks triad

• Confusion / encephalopathy

Complications of renal

failure

Complications of chronic

renal failure

• Fluid overload (as above)

• Uraemia (as above)

• Anaemia

– Conjunctival pallor

• Tertiary hyperparathyroidism

– Parathyroidetomy as indicated by horizontal

scar at base of neck

Complications of

immunosuppression

Complications of

immunosuppression

Malignancy:

• Skin cancer (SCC / BCC / malignant melanoma)

Steroid use:

• Cushingoid appearance (e.g. moon face, buffalo

hump, abdominal striae, purpura)

Stigmata of infection

Ciclosporin:

• Tremor, gum hypertrophy

What’s causing the

kidney disease?

Aetiology of ESRF

• Diabetes:

– Diabetic paraphernalia around bed

– Diabetic finger prick marks

– Subcut insulin injection sites

• HTN:

– Blood pressure

– Antihypertensives on drug chart

– Fundoscopy

• PCKD:

– Balottable kidneys

– Hepatomegaly from liver cysts

– Nephrectomy scar

– Look for III nerve palsy (PCA aneurysm)

• Vasculitis:

– Skin lesions or rheumatological disease

• Alports syndrome:

– Hearing aid

To finish…

Things to say to the

examiner…

• Urine dip:

– Blood (nephritic syndrome)

– Protein (nephrotic syndrome)

• Urine for MC&S

• Bloods:

– U&Es, FBC, rheumatology/autoimmune

screen

• Fluid balance

• Blood pressure

• Ultrasound scan

RECAP…

Structure of the renal exam

1. WIPER

2. Around the bed1. Diabetes monitoring

2. Hearing aid (Alports)

3. Drugs

3. Hands1. Fingerprick

monitoring

2. Cap refill, temperature

3. Asterixis (uraemia)

4. Tremor (ciclosporin)

4. Arms1. AV fistula (inspection,

palpation, auscultation)

2. Bruising, excoriations

3. Raise arm

4. Offer BP

5. Neck1. JVP

2. Tunneled lines

3. Parathyroidectomy scar

6. Face1. Mucous membranes

2. Conjunctival pallor

3. Skin malignancies / cushingoid facies / gum hypertrophy

7. Chest1. Skin turgor

2. Auscultate – pericardial rub

3. Lung bases + sacral oedema

8. Abdomen1. Inspect

– Scars (nephrectomy/RM)

– Tenchkoff catheter /

surrounding skin

– Inguinal masses

– Subcut injection sites

2. Palpate– Iliac fossa mass

– Ballot for enlarged native kidneys

3. Percuss – Dull mass in iliac fossa

– Shifting dullness

4. Bruit

9. Legs1. Oedema

Presentation…

Present your findings…

I have examined Mrs Smith…

1.Mode of current / previous renal replacement

• She also has a Rutherford-Morrison scar overlying the right lower

quadrant, with a smooth, non-tender palpable mass underlying it.

This is consistent with a renal transplant.

• I note she has a non-functioning right brachiocephalic fistula,

suggesting that haemodialysis was her previous mode of RRT

2.Adequacy of renal replacement

• She is clinically euvolaemic and has no stigmata of uraemia. Of

note, I cannot hear a pericardial rub.

3.Complications of renal failure

• She has no stigmata of anaemia

4.Complications of immunosuppression

• I have not identified any complications of immunosuppression,

such as infection or skin cancer. She does not appear

Cushingoid.

5.Clues as to cause of kidney failure

• I note a blood sugar monitoring kit at the bedside, fingerprick

marks and abdominal sites of insulin injection. This may suggest

diabetic nephropathy as the underlying cause of her renal failure.

In summary...

• Approach exam in standard peripheral to

central way (around bed > hands > arms etc...)

• Whilst looking for signs of:

1. Mode of current / previous renal replacement

2. Adequacy of renal replacement

3. Complications of renal failure

4. Complications of immunosuppression

5. Clues as to cause of kidney failure

COMMON QUESTIONS

What are the complications of

a fistula?

• Bleeding

• Stenosis

• Aneurysm

• Steal syndrome from ischemia

• High output cardiac failure

Complications of renal

transplantation?

• Surgical complications:

– bleeding, post op complications

• Medical

– rejection (acute/chronic)

– delayed graft function

– malignancy

– infection due to immunosuppression

– cardiovascular disease

What are the different types of

dialysis?

What are the indications for

acute dialysis?

• Refractory pulmonary oedema

• Persistent hyperkalaemia

• Refractory metabolic acidosis

• Uraemic pericarditis

• Uraemic encephalopathy

Renal screen bloods –

vasculitic/autoimmune

• Serum / urine protein electrophoresis

• dsDNA, ANA

• Serum complement

• cANCA, pANCA

• Anti-GBM

• Hep B, Hep C, HIV, syphilis